Pain Management More Complex in Patients with Psychiatric Disorders

Prescribing opiates to patients with psychiatric disorders can be complicated. First, it may be difficult to quantify pain in a patient with a psychiatric disorder. In addition, symptoms of a psychiatric disorder may actually be related to an addiction, says Laurence Westreich, MD, Clinical Associate Professor of Psychiatry at the New York University Langone Medical Center.

According to the National Institute on Drug Abuse, it's common for drug addiction and mental disorders to go hand-in-hand. Individuals with mood or anxiety disorders are twice as likely to suffer from addiction as individuals in the general population. The reverse is also true.

Below Dr. Westreich discusses how psychiatrists can navigate these complex issues to help ensure appropriate treatment for these patients.

PSYCHIATRIC DISORDERS AND COMORBID PAIN

Does pain perception differ in patients with psychiatric disorders?

Certain psychiatric disorders may alter pain perception. For example, individuals with generalized anxiety disorder or opioid addiction are more likely to interpret pain signals as more disturbing than other people.

Is there a higher prevalence of psychiatric disorders in patients with chronic pain conditions or vice versa?

I don't know if there are data available to demonstrate that this is the case, but it certainly seems likely.

A recent study showed that veterans with comorbid pain and mental health problems were more likely to receive opioids, but a second study showed this was not the case in a civilian population with psychiatric disorders. Why do you think this was the case?

I'm not certain why this is the case, but it may be because the veterans had co-occurring physical injuries for which they needed (or asked for) opioids.
It's important that psychiatrists be aware that legitimate pain and psychiatric disorders can co-exist.

Just because someone has a psychotic syndrome doesn't mean that they don't also have freestanding and very real pain.
However, if a psychiatrist is working with a patient who is taking opiates for physical injuries, it's important that he or she work with that physician prescribing the drugs to coordinate care. Psychiatrists should be alert for problems. For example, if a psychiatrist sees someone doubling or tripling the prescribed dose, that person may have an addiction problem. If this is the case, you may have to educate the patient's physician about the issue.

But note that a patient who needs a higher than typical dose of opiates doesn't always have a problem with addiction. A person with a history of opiate addiction may need more opioids to manage pain than the usual patient, due to the body's tolerance for the drug. This is not necessarily a problem.

MAKING THE RIGHT DIAGNOSIS

Can conditions related to opioid use (e.g., opioid intoxication, opioid withdrawal, substance-dependent disorders) confuse the diagnosis of psychiatric conditions? What are the recommendations to identify and distinguish between the two?

Yes, absolutely. Since the opioids are sedatives, patients who are illicitly taking them can appear depressed. They can also appear anxious when going through withdrawal. But this anxiety is due to their opioid withdrawal rather than any underlying condition. Similarly, patients with an undiagnosed opioid addiction can act in a sociopathic manner in their attempts to get drugs, but when the addiction is treated have no sociopathy at all.

But the opposite is also true. A physician may misinterpret under-treated pain in a patient with a psychiatric disorder as drug-seeking behavior. So it's important that psychiatrists not jump to conclusions too quickly when treating these patients.

A MULTIMODAL APPROACH TO TREATMENT

How should patients with psychiatric disorders and pain conditions best be managed?

A team approach can help sort through some of the complexities of opiate management. Psychiatrists and pain medicine specialists should collaborate when treating individuals with psychiatric disorders and pain conditions. In the event that the psychiatric disorder is a substance use disorder, an addiction psychiatrist and a pain medicine specialist should team up to coordinate treatment for that patient.

Are there alternatives to opioid treatment that can be considered for patients with psychiatric disorders and pain conditions?

There are numerous alternatives to opioids, which include complementary medicine, such as acupuncture and yoga. But alternatives are not always the best option. Opiates are a very effective pain medication. This issue would be easy if these drugs were just evil, but they're not. Just as it's unwise for doctors to think that they should prescribe opiates to all patients, it's also wrong to completely avoid opiate prescriptions. The proper course is to get a good clinical assessment of each individual. Work with a colleague on the case and try to treat the whole patient.